BUREAU FOR PUBLIC HEALTH OFFICE OF LABORATORY SERVICES WEST VIRGINIA Department of Health & Human 4710 Chimney Drive, Suite G, Charleston, WV 25302 Telephone (304) 965-2694 Fax (304) 965-2696 Resources ► INFORMATION R E Q U I R E D F O R LOCATION OF SAMPLE COLLECTION T E S T I N G SAMPLE COLLECTION INFORMATION ►PUBLIC WATER SYSTEM (PWS) ID: ►DATE COLLECTED: ►NAME OF SYSTEM: ►POINT OF COLLECTION: ►NAME OF OWNER: ►COLLECTED BY: ►PHYSICAL ADDRESS: ►COLLECTOR'S TITLE: (ONE) ►CITY/STATE/ZIP: ►PURPOSE OF SAMPLE: (ONE) Other (Comments?) ►COUNTY: ►PHONE: RESPONSIBLE PARTY FOR BILLING (if different than sample location) ►BUSINESS NAME: ►SOURCE OF WATER: (ONE) ►CONTACT NAME: ►MAILING ADDRESS: ► TYPE OF WATER: (ONE) ►CITY/STATE/ZIP: ►PHONE: FAX: Please call the laboratory (304965-2694 Ext. 0) for additional tests, a separate bottle may be required. Thank you! ☺ COMMENTS: □ □ □ □ □ □ □ □ □ □ PLACE BARCODE HERE LAB USE ONLY ► TIME: ►SAMPLE ID#: District Engineer Sanitarian Owner Regulatory Compliance Operator Complaint Customer Request Sanitary Survey Plant Review Special Purpose Lead Abatement Home Loan Well Purchased River/Creek Spring Other Impoundment Raw Treated Treated/Chlorinated Lab Pure Other (comments?) THE ANALYSES REQUESTED FOR CHEMISTRY TESTING ARE MARKED □ Manganese □ * Alkalinity, Total □ Magnesium □ Calcium □ * Combined Nitrate+Nitrite □ Mercury □ Calcium Hardness □ * Nitrate □ Nickel □ Selenium □ Chloride □ * Nitrite □ Chlorine, Free □ * Orthophosphate □ Silver □ Chlorine, Total □ pH □ Sodium □ * Conductivity □ * Sulfate □ Thallium □ * Cyanide, Free □ * TDS □ Zinc □ Fluoride □ Total Hardness □ * SUVA □ * Hydrogen Sulfide □ * Turbidity □ * TOC Aluminum Antimony Arsenic Barium Beryllium Cadmium Chromium Copper Iron Lead REMARKS: * These analytes require special sample bottles and preservatives, please contact the laboratory. Please remember that metals and non-metals are to be sampled in two separate bottles. LABORATORY USE ONLY KIT PREPARED BY: IDENTIFY SAMPLE PRESERVATIVE WHEN SHIPPED NO3 {+} NO2 DATE: CN TOC □ H2SO4 □ NaOH □ H3PO4 METHOD OF SHIPPING UPON RECEIPT: U.S.Mail RECEIVED BY: DATE RECEIVED: □ C6H8O6 APPROVED CONTAINER: Yes No REQUIRED VOLUME: Yes No CHAIN OF CUSTODY FORM: Yes No TEMPERATURE WHEN RECEIVED ON ICE: Hand Delivered Courier OTHER TIME RECEIVED: